A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse?
An assistive personnel is encouraging intake of oral fluids.
Supplemental oxygen is in use.
Benzodiazepines are administered every 4 hr.
A family member remains at the client's bedside 24 hr each day.
The Correct Answer is A
A. An assistive personnel is encouraging intake of oral fluids: For a client in the active dying phase, forcing or encouraging oral intake can cause discomfort, aspiration, or fluid overload. The focus should be on comfort rather than meeting standard hydration goals, so this requires intervention by the nurse.
B. Supplemental oxygen is in use: Oxygen may be provided for comfort if the client experiences dyspnea. Its use in the active dying phase is appropriate and does not require intervention unless it causes discomfort or is unnecessary.
C. Benzodiazepines are administered every 4 hr: Scheduled benzodiazepines can help manage anxiety, restlessness, or dyspnea in a dying client. This is an appropriate intervention for comfort and does not require nurse intervention.
D. A family member remains at the client's bedside 24 hr each day: Continuous presence of family provides emotional support and comfort for both the client and loved ones. This is consistent with hospice care principles and does not require nurse intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Raises all four side rails on the client's bed: Raising all four side rails can create a restraint situation, increasing the risk of entrapment or injury. Current safety guidelines recommend using only two side rails and employing other fall-prevention strategies instead.
B. Locks the wheels on the client's bed: This is a standard safety measure. Locking the wheels ensures the bed does not move when the client attempts to sit up or get out of bed, reducing fall risk. This is an appropriate safety measure for clients at risk for falls.
C. Assists the client to the bathroom every 2 hr: Regularly assisting the client to the bathroom reduces the likelihood of unassisted ambulation, which can prevent falls. Scheduled toileting is a recommended intervention for fall prevention.
D. Clears furniture from the path leading to the bathroom: Removing obstacles ensures a clear walking path and minimizes tripping hazards. Removing environmental hazards, such as clutter, loose rugs, or excess furniture, creates a clear, safe pathway for the client and reduces the risk of tripping.
Correct Answer is A
Explanation
A. “It is your choice to share personal information during group therapy.”: This statement supports client autonomy by emphasizing the client’s right to make decisions about their own participation and what personal information to disclose. Respecting autonomy involves allowing clients to make informed choices about their care and interactions.
B. "I will only discuss your medical information with the health care team.": This reflects the ethical principle of confidentiality, protecting privacy, but does not directly address autonomy.
C. “I will be truthful when answering questions about your treatment”: Truthfulness relates to veracity, ensuring honesty in the nurse-client relationship, but does not specifically promote autonomy.
D. "The nursing staff here will provide you with nonjudgmental care”: Providing nonjudgmental care supports beneficence and a therapeutic environment but does not directly empower the client to make their own decisions.
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